“Don’t trivialize psychological suffering,” Johan Braeckman and others write in response to our open letter, and this is about the best possible outcome we could have expected. It is the very essence of our argument.

We must, however, qualify the distinction objective/subjective as put forward in the response by Braeckman and others. Psychological suffering is obviously a subjective experience, that is clear, but a mental illness is always more than just subjective. The way the illness relates to objective factors is different than in the case of physical disorders. There is no tissue damage, no detectable degradation process in the brain: you cannot see in an autopsy if someone had a depression or not, which you can, for example, in the case of dementia.

But, contrary to what our critics suggest, brain scans do show changes, for example when someone suffers from depression. What is important is that these changes are functional and dynamic: what they show depends on when the scan is taken. They don’t have the irreversible character of tissue damage. Herein lies the fundamental difference with the subjective suffering in the case of physical ailments: you can objectively determine an irreversible process that underlies this suffering.

The person who plunges into a depression falls prey to a real feeling of lack of perspective. Clinical and research experience show, however, that even a succession of major depressive episodes doesn’t imply that the suffering is hopeless.

Suppose someone says, “I have failed in all areas of my life, professional, personal, familial,” and the therapist thinks otherwise on the basis of various specific elements that the patient previously mentioned. Is the only way to avoid being paternalistic or pedantic to simply respond to this patient: “Yes, You are right.”? No, the therapist will both respond to the reality that the patient experiences while also gently suggesting other angles. Clinical care is empathic, indeed, but it is also thoughtful empathy, which involves a gentle invitation to entertain a different perspective. Here, clinical ethics requires to be receptive to the feeling of hopelessness and to acknowledge it, without abandoning the ethical duty to also explore the horizon of other options.

Not trivializing psychological suffering means precisely this: taking account of its uniqueness. The course of a cancer is indifferent to the way the oncologist listens and speaks. Research shows that with mental problems, the relationship between patient and therapist is a decisive factor for the success of the treatment. That constitutes the fundamentally different reality of mental illness. The patient who suffers psychologically is fundamentally attached to the words of the therapist, while the cancer does not care about what the oncologist says.

This brings us to the crux of the ethical basis of the euthanasia legislation: the centrality of the value of autonomy. Testimonials from euthanasia cases involving patients with purely psychological suffering indicate that patients sometimes ask at the last minute: “You are sure, doctor, aren’t you, that nothing more can be done to help me?” Or “You really can confirm that my disease is incurable, isn’t it doctor? ” (see for example the case of Christophe, Knack, 10.22.2014).

This shows how the will of the patient is neither purely autonomous, or undivided, nor unambiguously expressed. In order to recognize the autonomy of a patient, you have to take into account how the will is divided and always probes what the other wants. The patient becomes far more articulate when she is empowered to explore the broad spectrum of her will, with the support of the therapist who continuously invites her to do so. The role of the therapist is in other words never that of a neutral expert who merely confirms the patient’s choice.

Obviously, this problem presents itself in the context of every euthanasia request, but in the context of physical conditions there is an unambiguous limitation as a result of objectively determinable irreversibility. This crucial containment factor is missing here. We are therefore concerned about how the law assigns a position of medical expert to the doctor in the context of issues that primarily concern interpersonal relations. The debate about euthanasia on grounds of mental suffering alone cannot be settled simply by referring to the virtue of diligence and the value of autonomy. Moreover, it is precisely because of the importance of autonomy as a core value that we have to be very careful with how we assign in our legislation an exceptional position to experts.

Even those who are deeply concerned about the right to self-determination should be sensitive to these concerns.